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WELL LOCATION MINNESOTA DEPARTMENT OF HEALTH MINNESOTA UNIQUE WELL NO. <br /> County Name WELL AND BORING RECORD 5 g 0 414 <br /> � I1i1E�>7.S` Minnesota Statutes Chapter 103/ <br /> Township Name Township No. Range No. Section No. Fraction WELL DEPTH(completed) Date Work Completed <br /> ft. <br /> Orono 117 2.3 (9 1 1. 11W f 7-9--96 <br /> House Number,Street Name,City,and Zip Code of Well Location or Fire Number DRILLING METHOD <br /> {'��, i- ❑ Cable Tool ❑ Driven IA Dug <br /> 870 Old Crystal Bay Road Orono, Mn. 5.1�-35 6 ❑ Auger XRotary ❑ Jetted <br /> Show exact location of well in section grid with"X". Sketch map of well location. ❑ <br /> Showing property lines, <br /> roads and buildings. DRILLING FLUID <br /> N 1's :t: ',.. <br /> USE ❑ Monitoring ❑ Heating/Cooling <br /> I L1Oomestic <br /> LI CommunityPWS <br /> -- ❑ Irrigation ❑ Industry/Commercial <br /> i <br /> 0 Noncommunity PWS ❑ Remedial <br /> w iI E T ❑ Test Well ❑ Dewatering p <br /> -ii --r---r- CASING Drive Shoe? 0 Yes 0 No HOLE DIAM. <br /> 1/2MileI 15 996 <br /> 0 Steel 10Threaded <br /> ❑ 0 Welded <br /> 'OV El Plastic <br /> 1 aile <br /> CASING DIAMETER WEIGHT <br /> PROPERTY OWNER'S NAME 4- in.to 101 ft. SUR. 21 lbs./ft. l%t o 31st. <br /> Lake Associates <br /> in.to ft. lbs./ft. E, 1,141.40 1 1 eft. <br /> Property owner's mailing address if different than well location address indicated above. t in.to ft. lbs./ft. in.to ft. <br /> 1212 East Wayzata Blvd. SCREEN .iO+i]I'L..0%1 OPEN HOLE <br /> Wayzata, Mn. 55391 Make ; `a iY from _ft.to ft. <br /> Type Stainless nless Steel Diam. ra <br /> Slot/Gauze 16/1(; Length G 61 <br /> Set between 101 ft.and 1 14, ft. FITTINGS: 11-6 <br /> STATICCNfATER LEVEL <br /> WELL OWNER'S NAME '-J'j ft. [below ❑ above land surface Date measured I-9-96 <br /> PUMPING LEL(below land surface) <br /> Well owner's mailing address if different than property owner's address indicated above. { ft. after 1 hrs.pumping ..0 _g.p.m. <br /> WELL HEAD COMPLETION <br /> .Pitless adapter manufacturer White ter Model <br /> ❑ Casing Protection 1312 in.above grade <br /> ❑ At-grade(Environmental Wells and Borings ONLY) <br /> GROUTING INFORMATION <br /> Well grouted? C2�Yes 0 No <br /> GEOLOGICAL MATERIALS COLOR HARDNESS OF FROM TO Grout Material ❑ Neat cement LXBentonie 0 Concrete El High Solids Bentonite <br /> MATERIAL <br /> from U to ,a ) ft. L 0 yds. liC bags <br /> Clay �_, t,,, y from to ft. ❑ yds. 10 bags <br /> Clay yery llc�r from to ft. 0 yds. ❑ bags <br /> NEAREST KNOWN SOURCE OF CONTAMINATION <br /> Clay Grey _. 70 <br /> feet direction type <br /> Well disinfected upon completion? Ql'es CI No <br /> C ;-;_.:t:J 1. __. 9o' Iii:' <br /> PUMP <br /> O Not installed �flazeiostaYed 7-10-96 <br /> Manufacturer's name fl >b 0l.e tr Y <br /> - Model number 1`' ' �'` HP 1�' Volts �u <br /> f <br /> Length of drop pipe /-) ft. Capacity 18 g.p.m. <br /> PressureTankCapacity f .n X-TIYA <br /> Type: fS Submersible ❑ L.S.Turbine 0 Reciting ❑ J ❑ <br /> -- ABANDONED WELLS <br /> Does property have any not in use and not sealed well(s)? 0 Yes 4.No <br /> - --- - VARIANCE <br /> Was a variance granted from the MDH for this well? ❑ Yes L No <br /> WELL CONTRACTOR CERTIFICATION <br /> Use a second sheet,if needed This well was drilled under my supervision and in accordance with Minnesota Rules,Chapter 4725. <br /> REMARKS,ELEVATION,SOURCE OF DATA,etc. The information contained in this report is true to the best of my knowledge. <br /> DON S1iODOLP WELL DRILLING CO., INC. 27172 <br /> Licensee Business Name Lic.or Reg.No. <br /> r.� <br /> 7 - G>• 'f�7- 8-28-96 <br /> Authorized Representative Signature Date <br /> erect Leiby 8-28-96 <br /> 5 8 0 414 Name of Driller Date <br /> LOCAL COPYHE-01205-05(Rev.1/95) <br />